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Jubouri M, Surkhi AO, Al-Tawil M, Geragotellis A, Abdaljawwad TZI, Qudaih M, Elrayes MIR, Dewi M, Moothathamby T, Hammad A, Mohammed I, Awad WI, D'Oria M, Piffaretti G, Bailey DM, Williams IM, Bashir M. LONG-TERM SURVIVAL AND REINTERVENTION FOLLOWING THORACIC ENDOVASCULAR AORTIC REPAIR IN BLUNT TRAUMATIC THORACIC AORTIC INJURY: A SYSTEMATIC REVIEW AND META-ANALYSIS. Ann Vasc Surg 2024:S0890-5096(24)00391-1. [PMID: 39004278 DOI: 10.1016/j.avsg.2024.04.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 04/02/2024] [Accepted: 04/28/2024] [Indexed: 07/16/2024]
Abstract
INTRODUCTION Blunt thoracic aortic injury (BTAI) represents one of the most devastating scenarios of vascular trauma. Different management strategies are available with varying clinical outcomes. However, thoracic endovascular aortic repair (TEVAR) has become the first-line option for most BTAI patients, mainly owing to its minimally invasive nature, yielding improved immediate results. This meta-analysis aims to investigate mortality, long-term survival, and reintervention following TEVAR in BTAI. MATERIAL AND METHODS A systematic review conducted a comprehensive literature search on multiple electronic databases using strict search terms. Twenty-seven studies met the set inclusion/exclusion criteria. A proportional meta-analysis of extracted data was conducted using the Comprehensive Meta-Analysis Software v.4. RESULTS 1498 BTAI patients who underwent TEVAR were included. Using the SVS grading system, 2.6% of the population had Grade 1 injuries, 13.6% Grade 2, 62.2% Grade, 19.6% Grade 4, and 1.9% unspecific. All-cause mortality did not exceed 20% in all studies except one outlier with a 37% mortality rate. Using the random-effects model, the pooled estimate of overall mortality was 12% (95%CI 5.35-8.55%; I2 = 70.6%). This was 91% (95%CI, 88.6-93.2; I2 = 30.2%) at 6 months, 90.1% (95%CI, 86.7-92.3; I2 = 53.6%) at 1-year, 89.2% (95%CI, 85.2-91.8; I2= 62.3%) at 2 years, and 88.1% (95%CI, 83.3-90.9; I2 = 69.6%) at 5 years. Moreover, the pooled estimate of reintervention was 6.4% (95%CI, 0.1-0.49%; I2 = 81.7%). CONCLUSION Despite the high morbidity and mortality associated with BTAI, TEVAR has proven to be a safe and effective management strategy with favourable long-term survival and minimal need for reintervention. Nevertheless, diagnosis of BTAI requires a high index of suspicion with appropriate grading and prompt transfer to trauma centres with appropriate TEVAR facilities.
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Affiliation(s)
- Matti Jubouri
- Hull York Medical School, University of York, York, UK
| | | | | | | | | | - Mohanad Qudaih
- Faculty of Medicine, Al-Quds University, Jerusalem, Palestine
| | - Mohammed I R Elrayes
- Department of Paediatric Surgery, Great Ormond Street Hospital for Children, London, UK
| | - Madlen Dewi
- Department of Vascular Surgery, University Hospital of Wales, Cardiff, UK
| | - Thurkga Moothathamby
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Aya Hammad
- Hull York Medical School, University of York, York, UK
| | - Idhrees Mohammed
- Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Science (SIMS Hospital), Chennai, Tamil Nadu, India
| | - Wael I Awad
- Department of Cardiothoracic Surgery, Barts Heart Centre, St Bartholomew's Hospital, London, UK
| | - Mario D'Oria
- Division of Vascular and Endovascular Surgery, Department of Medical Surgical and Health Sciences, University of Trieste, Italy
| | - Gabriele Piffaretti
- Vascular Surgery-Department of Medicine and Surgery, University of Insubria School of Medicine and ASST Settelaghi University Teaching Hospital; Varese-Italy
| | - Damian M Bailey
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK
| | - Ian M Williams
- Department of Vascular Surgery, University Hospital of Wales, Cardiff, UK
| | - Mohamad Bashir
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK; Vascular and Endovascular Surgery, Velindre University NHS Trust, Health Education and Improvement Wales (HEIW), Cardiff, UK.
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Baldaia L, Duque M, Silva M, Silva E, Nunes C, Constâncio V, Orelhas L, Fonseca M, Antunes LF. Thoracic aortic aneurysms, a single center's 10-years experience and analysis of outcomes. Vascular 2024:17085381241236575. [PMID: 38391289 DOI: 10.1177/17085381241236575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
INTRODUCTION Thoracic aortic aneurysms (TAAs) are an increasingly prevalent pathology with significant associated morbidity and mortality. Thoracic endovascular aortic repair (TEVAR) is the primary line of treatment. The purpose of this study was to analyse a single center's experience in the treatment of TAAs and identify possible risk factors for worse outcomes. METHODS A retrospective review of our institutional database was done to identify all patients treated for TAAs in a 10-year period, from 1 January 2012 to 31 December 2022. Data were extracted from patients' medical records. Primary outcome was all-cause mortality and secondary outcomes were procedure related morbidity (vascular access complications, medullary ischaemia, stroke, endoleaks, migration, aneurysm sac enlargement >5 mm) and need for reintervention at 1-, 6- and 12-month follow-up. A descriptive and inferential analysis of the data was performed. Statistical analyses were conducted using the IBM Statistical Package for Social Sciences (SPSS) software. RESULTS We identified 34 patients treated for TAAs in this period. Mean age was 68 years [47-87] and 79.4% of patients were male. Mean aneurysm diameter was 63 mm [35-100], 55.9% fusiform and 44.1% saccular. The majority (91.2%) were located at the descending thoracic aorta and 3 (8.8%) of them extended to the aortic arch. The most common aetiology was degenerative in 22 patients (64.7%), followed by aortic dissection in 8 patients (23.5%). Elective surgery was performed in 19 (61.3%) patients and 12 (38.7%) had urgent repair. TEVAR was the treatment of choice in 24 (77.4%) patients, and the remaining 7 (22.6%) were treated with hybrid surgery. Mean length of hospital stay was 10 days [2-80] (6 days for elective repair versus 16 days for urgent repair, p = .016). Follow-up period ranged from 1 month to 10 years. At 1 year follow-up, all-cause mortality was 15%, morbidity was 30% (with 6 (22%) patients having a type Ia endoleak) and need for reintervention was 22%. Aneurysm diameter was a significant risk factor for procedure related morbidity (median diameter of 73.5 mm versus 56.0 mm in patients with no morbidity; p = .027). The presence of type Ia endoleak was significantly associated with higher reintervention rates (p = .001), but not with higher mortality rates (p = .515). Age, female sex, aetiology and urgent repair weren't associated with any significant differences in the outcomes. CONCLUSIONS TEVAR proved to be effective in the treatment of TAAs, with good outcomes at short and mid-term follow-up. TAAs should be diagnosed earlier and be promptly treated when meeting criteria to prevent worse outcomes.
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Affiliation(s)
- Leonor Baldaia
- Department of Angiology and Vascular Surgery, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Mariana Duque
- Department of General Surgery, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Miguel Silva
- Department of Angiology and Vascular Surgery, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Eduardo Silva
- Department of Angiology and Vascular Surgery, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Celso Nunes
- Department of Angiology and Vascular Surgery, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Vânia Constâncio
- Department of Angiology and Vascular Surgery, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Luís Orelhas
- Department of Angiology and Vascular Surgery, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Manuel Fonseca
- Department of Angiology and Vascular Surgery, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Luís F Antunes
- Department of Angiology and Vascular Surgery, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal
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Mutter C, Benk J, Berger T, Kondov S, Chikvatia S, Humburger F, Rösslein M, Ulbrich F, Czerny M, Rylski B, Kreibich M. Retrospective investigation of >400 patients undergoing thoracic endovascular aortic repair with or without cerebrospinal fluid drainage. INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2023; 37:ivad178. [PMID: 37963056 PMCID: PMC10656091 DOI: 10.1093/icvts/ivad178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 10/20/2023] [Accepted: 11/11/2023] [Indexed: 11/16/2023]
Abstract
OBJECTIVES The aim of this study was to analyse the risks and benefits of cerebrospinal fluid drainage (CSFD) placement in patients undergoing thoracic endovascular aortic repair. METHODS Between 2009 and 2020, 411 patients underwent thoracic endovascular aortic repair in 1 institution where 236 patients (57%) received a preoperative CSFD. Patient and outcome characteristics were retrospectively analysed and compared between patients with and without preoperative CSFD placement. RESULTS Preoperative CSFD was performed significantly more frequently in elective patients, especially those undergoing distal stent graft extension following frozen elephant trunk-stent placement (P < 0.001). Significantly fewer CSFD was placed in patients with acute aortic injury (P < 0.001). The incidence of permanent spinal cord ischaemia (SCI) was higher in patients without preoperative CSFD [10 patients (2%) vs 1 patient (0.2%), P = 0.001]. Postoperative CSFD was placed in 3 patients (0.7%). Severe CSFD-associated complications affected 2 patients (0.5%) namely, a subdural spinal haematoma causing permanent paraplegia in one of those 2 patients. CONCLUSIONS CSFS placement is associated with low procedural risk and can potentially help to prevent SCI. However, the SCI incidence is most likely also associated with other preoperative factors including the patient's haemodynamics. Hence, a general recommendation for placing a preoperative CSFD cannot be made when relying on the present evidence.
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Affiliation(s)
- Charlotte Mutter
- Department of Cardiovascular Surgery, University Heart Centre Freiburg, University Medical Centre Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Julia Benk
- Department of Cardiovascular Surgery, University Heart Centre Freiburg, University Medical Centre Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Tim Berger
- Department of Cardiovascular Surgery, University Heart Centre Freiburg, University Medical Centre Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Stoyan Kondov
- Department of Cardiovascular Surgery, University Heart Centre Freiburg, University Medical Centre Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Salome Chikvatia
- Department of Cardiovascular Surgery, University Heart Centre Freiburg, University Medical Centre Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Frank Humburger
- Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
- Department of Anesthesiology and Intensive Care Medicine, University Medical Centre Freiburg, Freiburg, Germany
| | - Martin Rösslein
- Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
- Department of Anesthesiology and Intensive Care Medicine, University Medical Centre Freiburg, Freiburg, Germany
| | - Felix Ulbrich
- Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
- Department of Anesthesiology and Intensive Care Medicine, University Medical Centre Freiburg, Freiburg, Germany
| | - Martin Czerny
- Department of Cardiovascular Surgery, University Heart Centre Freiburg, University Medical Centre Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Bartosz Rylski
- Department of Cardiovascular Surgery, University Heart Centre Freiburg, University Medical Centre Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Maximilian Kreibich
- Department of Cardiovascular Surgery, University Heart Centre Freiburg, University Medical Centre Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
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Kreibich M, Berger T, Walter T, Potratz P, Discher P, Kondov S, Beyersdorf F, Siepe M, Gottardi R, Czerny M, Rylski B. Downstream thoracic endovascular aortic repair following the frozen elephant trunk procedure. Cardiovasc Diagn Ther 2022; 12:272-277. [PMID: 35800359 PMCID: PMC9253175 DOI: 10.21037/cdt-22-99] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 05/09/2022] [Indexed: 09/10/2023]
Abstract
The frozen elephant trunk technique has become a well-established treatment option for patients presenting all thoracic aortic pathologies including acute and chronic dissection, aortic aneurysms and even penetrating aortic ulcers involving the aortic arch and descending aorta. Nevertheless, there is a significant incidence of and risk for distal aortic reinterventions after the frozen elephant trunk. Indications mainly include a planned staged approach, diameter progression of downstream aortic segments and the development of distal stent-graft induced new entries (dSINEs). Endovascular stent-graft extension through conventional thoracic endovascular aortic repair (TEVAR) is a relatively simple and safe method to address any pathologies in the remaining descending thoracic aorta up to the level of the coeliac trunk. In fact, the frozen elephant trunk stent-graft provides an ideal proximal landing zone for any endovascular stent-graft extension. Postoperative outcomes are very promising with very low reported in-hospital mortality and morbidity. In case this 2-staged-approach fails to stabilize the remaining aorta, a 3-step procedure, namely open thoracoabdominal aortic replacement, is simplified because the anastomosis site has moved distally. Follow-up of all patients, following frozen elephant trunk implantation or distal stent-graft extension, is mandatory, ideally in an outpatient clinic dedicated to the aorta in order to identify disease progression or to detect any complications as soon as possible.
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Affiliation(s)
- Maximilian Kreibich
- Department of Cardiovascular Surgery, University Heart Center Freiburg, University Hospital Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Tim Berger
- Department of Cardiovascular Surgery, University Heart Center Freiburg, University Hospital Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Tim Walter
- Department of Cardiovascular Surgery, University Heart Center Freiburg, University Hospital Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Paul Potratz
- Department of Cardiovascular Surgery, University Heart Center Freiburg, University Hospital Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Philipp Discher
- Department of Cardiovascular Surgery, University Heart Center Freiburg, University Hospital Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Stoyan Kondov
- Department of Cardiovascular Surgery, University Heart Center Freiburg, University Hospital Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, University Heart Center Freiburg, University Hospital Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Matthias Siepe
- Department of Cardiovascular Surgery, University Heart Center Freiburg, University Hospital Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Roman Gottardi
- Department of Cardiovascular Surgery, University Heart Center Freiburg, University Hospital Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Martin Czerny
- Department of Cardiovascular Surgery, University Heart Center Freiburg, University Hospital Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Bartosz Rylski
- Department of Cardiovascular Surgery, University Heart Center Freiburg, University Hospital Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
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